Hepatic Encephalopathy Flashcards
What are 3 symptoms of overt HE?
- Altered mental status
- Fatigue
- Coma
What are 2 symptoms of sub clinical or minimal HE?
- Mild cognitive impairment
- Coordination declining
What is the best marker for HE?
Ammonium
Grade for encephalopathy: shortened attention span with mild asterixis or tremor and mild lack of awareness
1
Grade for encephalopathy: Lethargic, is disoriented with inappropriate behavior. Obvious aterixis and slurred speech
2
Grade for encephalopathy: somnolent but arousable, gross disorientation with bizarre behavior. Has muscular rigidity and clonus; hyperflexia
3
Grade for encephalopathy: Coma with decerebrate posturing
4
What are 4 precipitating factors of HE?
- Therapy non-compliance
- TIPS
- Medications (benzodiazepines, narcotics)
- Upper GI bleed
True or false: you should restrict protein in HE
False
What MOA do you want the medications to have to treat HE?
Decrease nitrogen load in the GI tract
What are 2 treatments for HE?
- Lactulose
- Rifaximin
What is the MOA of lactulose?
Cathartic; reduces nitrogen absorption in the GI due to increased transit
What is lactulose metabolized to?
Acetic acid and lactic acid
What is the dosing for lactulose?
30-45 mL (20-30 g) Q4-6
How many bowel movements do you want for a titration of lactulose?
2-3 loose stool bowel movements daily
For a retention enema what is the dose for lactulose?
300 mL lactulose + 700 mL saline
What are 2 nonobvious symptoms of lactulose?
- Hyponatremia
- Hypokalemia
What does rifaximin decrease?
Urease producing bacteria in the GI tract
What is the dose for rifaximin?
550 mg BID
What are 5 ADRs of Rifaximin?
- Abdominal pain
- Nausea
- Flatulence
- Dizziness
- Headache
What drug has better compliance?
Rifaximin
What is selection for Rifaximin and lactulose depend on?
Insurance
What are 6 causes of liver disease?
- Alcoholic hepatitis
- Fatty liver/MASH
- Drug induced liver disease
- Hepatitis
- Hemochromatosis
- Wilson’s disease
What 3 major lesions can occur in alcoholic liver disease?
- Fatty liver
- Cirrhosis
- Alcoholic lesions
Alcoholic hepatitis is _____ hepatic inflammation
Acute
What are 3 mechanisms of injury for alcoholic hepatitis?
- Ethanol metabolism
- Inflammation
- Innate immunity
What is the cardinal symptom of alcoholic hepatitis?
Acute jaundice
What are 4 clinical presentations of alcoholic hepatitis?
- Acute jaundice
- Fever
- New onset ascites
- Hepatomegaly
What does the modified discriminate function (mDF) score need to be in order to treat?
32
What criteria allows for corticosteroids to be used?
- mDF >32
- Hepatic encephalopathy
What corticosteroid is utilized for HE?
Prednisone (40 mg)
What 4 things are contraindicated for the use of steroids?
- Infection
- GI bleed
- Acute pancreatitis
- Renal failure
Pentoxifylline
TRENTAL
What is the MOA of TRENTAL?
Phosphodiesterase inhibitor and decreased transcription of the TNF-a promoter
True or false: pentoxifylline is used as second line therapy to steroids
True
When are patients able to get a liver transplant?
If they have 6 months of documented alcohol abstinence
